Effects of personalized colorectal cancer risk information on laypersons' interest in colorectal cancer screening: The importance of individual differences

Using Online Colorectal Cancer Risk Calculators to Guide Screening Decision-Making

BACKGROUND

Several online calculators estimate colorectal cancer risk, but their consistency is unknown. Our objectives were to quantify the variation in predicted risk and to determine which calculators are best used in the clinical setting.

METHODS

We used the Google search engine to identify online colorectal cancer risk calculators and assessed the output of each for 3 hypothetical screening scenarios (low-, average-, and high-risk), varied by age (50, 62, 75 years), sex, and race (Black, White), with risk levels based on risk-appropriate values for variables in each model. Estimated risks for models within a given scenario were rated as consistent or inconsistent based on comparison with either the absolute magnitude of difference or average lifetime risk of colorectal cancer. Summary statistics for consistent and inconsistent estimates were compared using chi-square and Fisher's exact tests.

RESULTS

We identified 5 online colorectal cancer risk calculators. Inconsistencies were found in none of 5-year, 19% of 10-year, and 81% of lifetime colorectal cancer risk estimate comparisons (P < .001). For a 50-year-old, 22% of risk estimate comparisons were inconsistent, vs 33% for a 62-year-old, and 36% for a 75-year-old (P = 0.14).

CONCLUSIONS

Online colorectal cancer risk models are more consistent in predicting colorectal cancer risk for 5- and 10-year time frames compared with lifetime. For a US population, the National Cancer Institute's Colorectal Cancer Risk Assessment Tool is a rigorously developed calculator that can be used in the clinical setting to provide 5-year and lifetime risk estimates.

Randomized Controlled Trial of Personalized Colorectal Cancer Risk Assessment vs Education to Promote Screening Uptake

INTRODUCTION

Risk stratification has been proposed as a strategy to improve participation in colorectal cancer (CRC) screening, but evidence is lacking. We performed a randomized controlled trial of risk stratification using the National Cancer Institute's Colorectal Cancer Risk Assessment Tool (CCRAT) on screening intent and completion.

METHODS

A total of 230 primary care patients eligible for first-time CRC screening were randomized to risk assessment via CCRAT or education control. Follow-up of screening intent and completion was performed by record review and phone at 6 and 12 months. We analyzed change in intent after intervention, time to screening, overall screening completion rates, and screening completion by CCRAT risk score tertile.

RESULTS

Of the patients, 61.7% of patients were aged <60 years, 58.7% female, and 94.3% with college or higher education. Time to screening did not differ between arms (hazard ratio 0.78 [95% confidence interval (CI) 0.52-1.18], P = 0.24). At 12 months, screening completion was 38.6% with CCRAT vs 44.0% with education (odds ratio [OR] 0.80 [95% CI 0.47-1.37], P = 0.41). Changes in screening intent did not differ between the risk assessment and education arms (precontemplation to contemplation: OR 1.52 [95% CI 0.81-2.86], P = 0.19; contemplation to precontemplation: OR 1.93 [95% CI 0.45-8.34], P = 0.38). There were higher screening completion rates at 12 months in the top CCRAT risk tertile (52.6%) vs the bottom (32.4%) and middle (31.6%) tertiles (P = 0.10).

DISCUSSION

CCRAT risk assessment did not increase screening participation or intent. Risk stratification might motivate persons classified as higher CRC risk to complete screening, but unintentionally discourage screening among persons not identified as higher risk.

An Electronic Questionnaire to Survey Colorectal Cancer Screening Status and Identify High-Risk Cohorts in Large Health Care Organizations

Though improved screening practices have reduced the incidence and mortality of colorectal cancer (CRC), screening rates continue to be suboptimal. This is especially true of high-risk individuals, who are difficult for clinicians to identify during a typical health care encounter. The authors developed an electronic patient questionnaire that determined an individual's CRC screening status and identified high-risk individuals. The questionnaire was administered to employees through the Department of Human Resources. The response rate was 44.7%; 81.2% of respondents aged ≥50 years were up-to-date on CRC screening; 878 high-risk individuals were identified, 77.7% of whom were up-to-date on CRC screening. However, among high-risk individuals aged 40 to 49 years, only 45.8% reported up-to-date CRC screening. The questionnaire was effective in measuring CRC screening rates and identifying high-risk individuals. Dissemination by the Department of Human Resources was novel, effective, and was not dependent on a health care encounter to assess screening or high-risk status.

Effects of Personalized Risk Information on Patients Referred for Lung Cancer Screening with Low-Dose CT

Background. Low-dose computed tomography (LDCT) screening for lung cancer is a preference-sensitive intervention that should ideally be individualized according to patients' likelihood of benefit and personal values. Personalized cancer risk information (PCRI) may facilitate this goal, but its effects are unknown. Objective. To evaluate the effects of providing PCRI to patients referred for LDCT screening. Design. Mixed-methods, pre-post study using surveys administered to patients before and after provision of PCRI-calculated by the PLCOm2012 risk prediction model-in shared decision-making consultations, and postvisit qualitative interviews. Setting. Centralized specialty-based LDCT screening program at a tertiary care hospital. Participants. Convenience sample of eligible patients referred for LDCT screening. Measurements. Pre- and postvisit surveys assessed patients' 1) perceived lung cancer risk, 2) uncertainty about their risk, 3) minimum risk threshold for wanting screening, 4) interest in LDCT screening, and 5) interest in smoking cessation. Qualitative interviews explored patients' perceptions of the value of PCRI. Screening uptake was assessed by chart review. Results. Sixty of 70 (86%) patients received PCRI and completed pre-post surveys, and 17 patients (28%) completed qualitative interviews. Perceived lung cancer risk decreased from 52% previsit to 31% postvisit (P < 0.0001). However, patients' minimum risk thresholds for screening decreased, their screening interest increased, and all patients completed screening. Qualitative interviews corroborated these effects, suggesting that patients discount and interpret PCRI according to preexisting beliefs and attitudes. Limitations. The study population was a relatively small, single-institution sample of patients referred for screening. Conclusions. Personalized cancer risk information decreases cancer risk perceptions of patients referred for LDCT screening, but has complex effects on screening-related judgments and decisions. The value of PCRI for patients considering LDCT screening requires further investigation.

A targeted promotional DVD fails to improve Māori and Pacific participation rates in the New Zealand bowel screening pilot: results from a pseudo-randomised controlled trial

BACKGROUND

New Zealand's Bowel Screening Pilot (BSP) used a mailed invitation to return a faecal immunochemical test. As a pilot it offered opportunities to test interventions for reducing ethnic inequities in colorectal cancer screening prior to nationwide programme introduction. Small media interventions (e.g. educational material and DVDs) have been used at both community and participant level to improve uptake. We tested whether a DVD originally produced to raise community awareness among the Māori population would have a positive impact on participation and reduce the proportion of incorrectly performed tests (spoiled kits) if mailed out with the usual reminder letter.

METHODS

The study was a parallel groups pseudo-randomised controlled trial. Over 12 months, all Māori and Pacific ethnicity non-responders four weeks after being mailed the test kit were allocated on alternate weeks to be sent, or not, the DVD intervention with the usual reminder letter. The objective was to determine changes in participation and spoiled kit rates in each ethnic group, determined three months from the date the reminder letter was sent. Participants and those recording the outcomes (receipt of a spoiled or non-spoiled test kit) were blinded to group assignment.

RESULTS

2333 Māori and 2938 Pacific people participated (11 withdrew). Those who were sent the DVD (1029 Māori and 1359 Pacific) were less likely to participate in screening than those who were not (1304 Māori and 1579 Pacific). Screening participation was reduced by 12.3% (95% CI 9.1-15.5%) in Māori (13.6% versus 25.9%) and 8.3% (95% CI 5.8-10.8%) in Pacific (10.1% versus 18.4%). However, spoiled kit rates (first return) were significantly higher among those not sent the DVD (33.1% versus 12.4% in Māori and 42.1% versus 21.9% in Pacific).

CONCLUSION

The DVD sent with the reminder letter to BSP non-responders reduced screening participation to an extent that more than offset the lower rate of spoiled kits.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry ACTRN12612001259831 . Registered 30 November 2013.

Reactions to online colorectal cancer risk estimates among a nationally representative sample of adults who have never been screened

Data on the public's reactions to online tailored colorectal cancer (CRC) risk estimates are sparse. We assessed among 560 men and women aged 50-75 with no CRC screening history reactions to online tailored CRC estimated comparative risk (i.e., self vs. other their age and sex). Assessed were reactions to estimate (i.e., repeating back estimate, match between perceived comparative risk and estimate, accuracy and usefulness of estimate, emotional reactions), risk appraisals and screening intentions. 73% of the sample accurately repeated back their estimate; the match between perceived comparative risk and the estimate was lowest among those informed of being at higher risk. Higher estimates were viewed as less useful and evoked more negative emotions. Viewing the estimate as more useful and experiencing more negative emotions were related with higher risk appraisals and, in turn, screening intentions. These data indicate that adults at higher comparative risk resist accepting a higher risk status.

Ethical issues with colorectal cancer screening-a systematic review

RATIONALE, AIMS, AND OBJECTIVES

Colorectal cancer (CRC) screening is widely recommended and implemented. However, sometimes CRC screening is not implemented despite good evidence, and some types of CRC screening are implemented despite lack of evidence. The objective of this article is to expose and elucidate relevant ethical issues in the literature on CRC screening that are important for open and transparent deliberation on CRC screening.

METHODS

An axiological question-based method is used for exposing and elucidating ethical issues relevant in HTA. A literature search in MEDLINE, Embase, PsycINFO, PubMed Bioethics subset, ISI Web of Knowledge, Bioethics Literature Database (BELIT), Ethics in Medicine (ETHMED), SIBIL Base dati di bioetica, LEWI Bibliographic Database on Ethics in the Sciences and Humanities, and EUROETHICS identified 870 references of which 114 were found relevant according to title and abstract. The content of the included papers were subject to ethical analysis to highlight the ethical issues, concerns, and arguments.

RESULTS

A wide range of important ethical issues were identified. The main benefits are reduced relative CRC mortality rate, and potentially incidence rate, but there is no evidence of reduced absolute mortality rate. Potential harms are bleeding, perforation, false test results, overdetection, overdiagnosis, overtreatment (including unnecessary removal of polyps), and (rarely) death. Other important issues are related to autonomy and informed choice equity, justice, medicalization, and expanding disease.

CONCLUSION

A series of important ethical issues have been identified and need to be addressed in open and transparent deliberation on CRC screening.